THE ACTUAL VERSUS EXPECTED HEALTH CARE USE AMONG HEALTHY KIDS ENROLLEES A REPORT PREPARED FOR THE HEALTHY KIDS BOARD OF DIRECTORS Christine A. Bono, MA Program Associate Elizabeth Shenkman, PhD Principal Investigator June 2001 Tallahassee, Florida
BACKGROUND As part of the program evaluation, the Healthy Kids Corporation is monitoring, on an ongoing basis, the extent to which enrollees are using health care services in a manner consistent with their expected pattern of use. The Healthy Kids Program was designed to improve children s access to health care through the provision of insurance premiums and a private-sector provider network. Ensuring that children are using the appropriate amount of health care services is an important measure of their access to care while in the program. In addition, measuring the expected number of health care visits based on the children s diagnoses, and comparing this number to the actual number of health care visits the children made is an essential process measure of health care quality. 1 Particularly in a managed care environment where some consumers, health care providers, and policy makers are concerned about potential underuse of health care services, it is important to conduct an ongoing evaluation of the appropriateness of the children s health care use. Because the Healthy Kids Program is operating at many different sites and working with many different managed care companies, it is useful to compare the patterns of health care use across sites. However, such comparisons can be difficult to make unless the health care needs of the enrollees at each site are taken into consideration. Various methods have been developed to assess the risk that a provider or a managed care company has for experiencing high health care use and/or morbidity. Risk adjustment methods allow for meaningful comparisons of health care use from one setting to another by controlling for differences in patient severity. These methods can also be used to predict health care use and costs, thereby enhancing the ability of health care providers and administrators to plan effectively for their patient populations. Page 1
As part of the Healthy Kids Program evaluation, we analyze the impact of gender, age, and diagnosis on health care use using a software program called the Ambulatory Care Groups (ACG) Case-Mix Adjustment System. 2 The purpose of this report is to: 1. Describe the case-mix of the Healthy Kids by site. For purposes of confidentiality, the data are presented for Site 1 through Site 24, rather than by county name or health plan name (Site 16 is not included in this report see paragraph below for details). 2. Present information about the health care use of the Healthy Kids for January 1, 2000 through December 31, 2000 at each site. Present information about how the actual use compares to the use that was expected based on the casemix of the enrollees. DESCRIPTION OF THE HEALTHY KIDS ENROLLEES CASE-MIX AT EACH SITE We conducted an analysis of the case-mix of the Healthy Kids enrollees in twenty-three sites, representing sixty of the sixty-seven counties in Florida. Hardee, Hendry, Highlands, Okechobee, Glades, St. Lucie, and Martin county were not included in this report. These counties were not included in this report since the health plans covering these counties was not in operation during the entire twelve-month time frame mentioned above. These counties will be included in future reports. Counties who are served by the same health plan and are contiguous, were combined to yield stable results (see attached map). The Healthy Kids data used in this analysis were obtained from the claims/encounter data provided by each managed care organization (MCO) participating in the Healthy Kids Program. Page 2
The ACG system also classifies children who are enrolled in health care programs but do not use health care services (See Table 1 and Table 2 - ACG Category 52). Understanding the behavior of non-users is important when evaluating the quality of health care. For example, in capitation rate development and other prospective applications, non-users are of great importance, since many of those enrollees are not using services in a current time period will consume services during a future time period. Since capitation payments are made regardless of whether the member ever interacts with the provider, the characteristics of non-users are also important. In general, population-oriented analyses will have more flexibility and be more comprehensive if both users and non-users are included. 3 For this portion of the analysis, we categorized all children enrolled (for at least six months) in the Healthy Kids Program between January 1, 2000 and December 31, 2000 into one of 53 mutually exclusive ACGs. The number of children and the mean number of visits they made according to each ACG category are displayed in Table 1. Table 1 is intended to provide detailed information at the level of each specific ACG for those who are interested in reviewing this material. Table 2 contains specific information for Healthy Kids enrollees in terms of the number of children and their mean visits by ACG category collapsed across all program sites listed above. Table 3 summarizes the mean number of visits across all ACG categories for each site. Page 3
ACTUAL VERSUS EXPECTED HEALTH CARE USE BY SITE USING THE AMBULATORY CARE GROUPS PROGRAM Table 4 contains a comparison of the actual versus the expected health care use at each site for Healthy Kids enrollees both before and after adjusting for case-mix. Column 1 Column 1 represents the program site. All sites are anonymous to preserve confidentiality. The exact site names are reported to the Healthy Kids Corporation Executive Director. Column 2 Column 2 contains the actual mean number of health care visits that were delivered at each site. Column 3 This column contains the actual average number of visits across all program sites. The average number of visits is derived from summing the visits across all of the Healthy Kids sites previously listed and dividing by the number of children making those visits. Column 4 This column contains the actual to the group average without adjusting for case-mix. That is, we first divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. A value of 1.00 indicates that the actual use and the expected use are identical. Values below 1 indicate underuse of health care services and values over 1 indicate overuse of health care services. For example, at Site 4, the unadjusted actual versus expected number of encounters is simply 2.22/2.24=0.99. The ratio of 0.99 means that without Page 4
adjusting for case-mix, there appears to be an almost perfect use of health care services at Site 4. Without adjusting for case-mix, it appeared that Site 5, Site 17, Site 18, Site 19, Site 20, Site 23 and Site 24 had some possible underuse of health care services; and Site 6, Site 8, Site 9, Site 11, Site 13, Site 14 and Site 21 appeared to have some possible overuse of health care services. Column 5 Column 5 shows the expected number of encounters at each site after adjusting for case-mix. Column 6 We then divided the actual number of visits at each site by the expected number of visits based on the case-mix adjustment. For example, at Site 4 the adjusted actual versus expected number of encounters is simply 2.22/2.16=1.03. The ratio of 1.03 means that after adjusting for case-mix, there still appears to be an almost perfect use of health care services at Site 4. After adjusting for case-mix, none of the sites had an underuse of health care services; and only one of the sites had an overuse of health care services (Site 14). Page 5
SUMMARY 1. The ACG Program is designed to assess the illness burden or the amount of health care that a group of enrollees requires based on International Classification of Diseases (ICD-9 codes). In general, children in the Healthy Kids Program are receiving the amount of health care that would be expected based on their health care needs. In fact, at Sites 2 and 3, the actual health care use is almost exactly what would be expected based on the case-mix of the children enrolled at that site. This is an important finding for two reasons. First, nationally there is some concern that children may not receive adequate care in health maintenance organizations (HMOs) due to strict utilization controls. This is not the case in the Healthy Kids Program. Children in this program are receiving the expected care based on their diagnoses, which is one component of a high quality health care program. Second, this finding has implications for the financing of the Healthy Kids Program. Specifically, this finding indicates that the financial resources are being used wisely. 2. The ACG software continues to be a useful tool when making comparisons across sites. As shown in Table 4, without adjusting for case-mix, seven sites had an underuse of health care services (Site 5, Site 17, Site 18, Site 19, Site 20, Site 23 and Site 24); and seven sites had an overuse of health care services (Site 6, Site 8, Site 9, Site 11, Site 13, Site 14 and Site 21). However, after adjusting for case-mix, none of the sites had an underuse of health care services; and only one of the sites had an overuse of health care services (Site 14). Thus in summary, only one of the twenty-three sites had less than optimal health care usage (e.g., less than optimal meaning either too low or too high). 3. This analysis did include those who were enrolled but did not use health care services (ACG Category 52). Understanding the number of children at each site who fail to use health care services is a critical component when evaluating health care quality and access to care. Page 6
4. We will continue to repeat this analysis each year to assess the children s health care use and to monitor trends across time within the Healthy Kids Program. Assessing the degree, to which children are receiving health care based on their needs, is an important process measure of health care quality. Page 7
1 Durch JS, (ed). Protecting and Improving Quality of Care for Children Under Health Care Reform: Workshop Highlights. Washington, DC: National Research Council, Institute of Medicine; 1994. 2 See the June 1996 Board Report or contact the Institute for Child Health Policy for further information. 3 The Johns Hopkins University ACG Case Mix Adjustment System: Documentation for PC-DOS and Unix, January 1998. Page 8
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